MEDICARE: MR. ROGER MRAZEK LCPC,CADC,CEAP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YP2500X	Professional Counselor	180000808	IL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	000-163-6162	OTHER	IL	BLUE CROSS BLUE SHIELD

General Provider Information

NPI Number	:	1811063621
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. ROGER MRAZEK LCPC,CADC,CEAP

Provider Business Mailing Address
First Line	:	1335 S. PRAIRIE AVE. #1503
Second Line	:	CHICAGO
City	:	CHICAGO
State	:	IL
Zip	:	60605-3138
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	2445 W 112TH ST
Second Line	:	CHICAGO
City	:	CHICAGO
State	:	IL
Zip	:	60655-1351
Country	:	US
Telephone Number	:	773-879-8696
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/27/2006
Last Update Date	:	07/08/2007

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